ORIGINAL ARTICLEONLINE FIRST

Randomized Trial to Evaluate the Efficacy
of Cognitive Therapy for Low-Functioning Patients
With Schizophrenia
Paul M. Grant, PhD; Gloria A. Huh, MSEd; Dimitri Perivoliotis, PhD; Neal M. Stolar, MD, PhD; Aaron T. Beck, MD

Context: Low-functioning patients with chronic schizo-

phrenia have high direct treatment costs and indirect costs
incurred due to lost employment and productivity andhave a low quality of life; antipsychotic medications andpsychosocial interventions have shown limited efficacy
to promote improved functional outcomes.
Objective: To determine the efficacy of an 18-monthrecovery-oriented cognitive therapy program to improve psychosocial functioning and negative symptoms(avolition-apathy, anhedonia-asociality) in lowfunctioning patients with schizophrenia.
Design, Setting, and Participants: A single-center,18-month, randomized, single-blind, parallel group trial
enrolled 60 low-functioning, neurocognitively impaired patients with schizophrenia (mean age, 38.4 years;
33.3% female; 65.0% African American).
Interventions: Cognitive therapy plus standard treatment vs standard treatment alone.
Main Outcome Measures: The primary outcome measure was the Global Assessment Scale score at 18 months
after randomization. The secondary outcomes were scoreson the Scale for the Assessment of Negative Symptoms
and the Scale for the Assessment of Positive Symptoms
at 18 months after randomization.

Results: Patients treated with cognitive therapy showeda clinically significant mean improvement in global functioning from baseline to 18 months that was greater than
the improvement seen with standard treatment (withingroup Cohen d, 1.36 vs 0.06, respectively; adjusted mean[SE], 58.3 [3.30] vs 47.9 [3.60], respectively; P=.03; between-group d=0.56). Patients receiving cognitive therapy
as compared with those receiving standard treatment also
showed a greater mean reduction in avolition-apathy (adjusted mean [SE], 1.66 [0.31] vs 2.81 [0.34], respectively;
P=.01; between-group d=−0.66) and positive symptoms(hallucinations, delusions, disorganization) (adjusted mean[SE], 9.4 [3.3] vs 18.2 [3.8], respectively; P=.04; betweengroup d=−0.46) at 18 months. Age was controlled in theanalyses, and there were no meaningful group differences
in baseline antipsychotic medications (class or dosage) orin medication changes during the course of the trial.
Conclusion: Cognitive therapy can be successful in promoting clinically meaningful improvements in functional
outcome, motivation, and positive symptoms in lowfunctioning patients with significant cognitive impairment.
Trial Registration: clinicaltrials.gov Identifier:

NCT00350883
Arch Gen Psychiatry. 2012;69(2):121-127.
Published online October 3, 2011.
doi:10.1001/archgenpsychiatry.2011.129

B

Author Affiliations: Perelman
School of Medicine, Universityof Pennsylvania, Philadelphia(Drs Grant, Stolar, and Beckand Ms Huh); and Veterans
Affairs San Diego Healthcare
System, San Diego, California(Dr Perivoliotis).

ETWEEN 2 AND 3 MILLION
American adults currently
have schizophrenia.1 The
modal onset is in early
adulthood, 2 and roughly
two-thirds of affected individuals experience a chronic or fluctuating course of illness.3 Annual overall direct treatment
costs and indirect costs incurred due tolost employment and productivity
approach $63 billion in the United States
or an average of between $26 000 and$31 000 per patient,4 which is 5 times the
per-patient cost of depression.5 Although
antipsychotic medications have been
demonstrated to reduce hallucinations
and delusions, one-third to one-half of

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patients with schizophrenia continue toexperience residual symptoms or haveintolerable adverse effects.6,7 The disorganized (speech disturbance) and negative(affective flattening, alogia, apathy, anhedonia, and asociality) symptoms ofFor editorial comment
see page 119
schizophrenia are even less responsive tothe medications than hallucinations anddelusions. 8 Importantly, the effect of
medications on functional outcomes has
been modest, even when medication regimens have been optimized.9

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Starting in the 1950s, patients with schizophrenia havebeen moved from mental hospitals to the community.10
In Philadelphia, Pennsylvania, for example, patients enrolled in community mental health centers are offeredsupported housing and a wide range of therapeutic andvocational services; however, a large proportion continue to function at a low level. We sought to determine
whether a novel version of cognitive therapy (CT) would
lead to an increase in functioning and decreases in negative symptoms and positive symptoms (hallucinations,
delusions, and disorganization) in this population. To determine the efficacy of this targeted CT derived from basic research and adapted to this population, we selecteda sample of patients who were on the low end of the continuum of psychosocial functioning. This sample was also
neurocognitively impaired (difficulties with information processing on tasks of memory, attention, and executive functioning) and experienced residual positive
symptoms. Cognitive therapy (often labeled cognitive behavior therapy) has an extensive empirical basis in theory11
and has been successfully applied to a wide range of psychiatric problems.12 It was initially applied to schizophrenia by investigators in the United Kingdom,13 andresults demonstrated success at reducing positive andnegative symptoms.14-17 Despite these encouraging findings, studies of CT have not focused on those patientswith neurocognitive impairment and poor functioning.
Similarly, studies of other psychosocial, behavioral, or
neurocognitive remediation interventions have been limited by the following: a focus on acute rather than chronic
psychosis, inclusion of a heterogeneous sample of patients, or a failure to find that treatment effects generalize adequately to psychosocial functioning.18-22
In adapting CT for low-functioning patients with schizophrenia, we shifted the emphasis from the predominantly
symptom-oriented approach that typifies the UK protocols
to a person-oriented therapeutic approach by highlighting
the patients’ interests, assets, and strengths. The objective
was to improve the level of functioning in the form of enhanced productivity, independence, and quantity and quality of social interactions. We developed the framework forour therapy from the finding that dysfunctional beliefs, inconjunction with neurocognitive impairment, impede
functioning.23-26 In addition, our therapy is largely influenced
by the principles and spirit of the Recovery Movement.27,28
We focused our treatment methods on identifying and promoting concrete goals for improving quality of life and reintegration into society. In adapting our treatment protocol to this highly regressed group, we decided to extend theduration of treatment from the originally planned 12 months
to 18 months. Further, we decided to focus on global functioning as a more appropriate measure of progress than simply the reduction of negative symptoms. Our protocol, insummary, differs from previous CT protocols for patientswithschizophreniainbeingexplicitlyrecoveryoriented,goal
directed, and adapted for neurocognitive and skills impairments; it treats functional outcomes as primary rather thansecondary targets of therapy and uses therapeutic conceptualizations based on new research on dysfunctional beliefs.
We conducted a randomized controlled trial to evaluate the efficacy of CT for neurocognitively impaired, poorly
functioning patients with chronic schizophrenia.

METHODS
The trial was conducted at a single center. The protocol andconsent form were approved by 2 institutional review boards(the University of Pennsylvania and the City of Philadelphia).
Each participant gave written informed consent before enrollment. Eligibility criteria included the following: diagnosis of
DSM-IV schizophrenia or schizoaffective disorder; prominent
negative symptoms (at least moderate severity on 2 Scale for
the Assessment of Negative Symptoms29 global subscales, ormarked severity on 1 subscale); aged 18 to 65 years; proficientin English; and able to give informed consent. Exclusion criteria included the following: neurologic disease or damage thatwould compromise cognitive functioning; and physical handicaps that would interfere with assessment procedures or therapy
attendance. Diagnosis of schizophrenia or schizoaffective disorder was determined on a consensus best-estimate basis byresearch personnel (with PhD and MD degrees) using a structured interview conducted by an assessor trained to criterion(intraclass correlation⬎0.80).30 Figure 1 indicates the number of individuals who were screened and reasons for those who
were not enrolled. Examples of reasons that patients gave forrefusing the initial assessment included having an unstable living situation, having medical problems, or not wanting to receive one of the study conditions.

INTERVENTIONSParticipants were randomly assigned (1:1, stratified by sex because females with schizophrenia have a better course31 and may
respond better to CT32) to the study intervention condition, CT
plus standard treatment (ST), or to the control condition, ST
alone, using an encrypted computer-generated randomization
list. Personnel enrolling patients did not have access to this list.
A single-blind design was used in which outcome assessors were
not aware of assigned study condition. To maintain blinding,the assessment team was managed separately from the therapy
team (in terms of personnel, physical location, and file access), and all participants were trained to not reveal their study
condition prior to each follow-up assessment. (A total of 3 patients broke this rule at the 18-month assessment, 2 receiving
CT and 1 receiving ST. Two of these patients were rated as unchanged on the primary outcome measure; 1 patient receiving
CT was rated as improved modestly [6 points]. Even if this latter rating were inflated, it does not alter the pattern or significance of the results.) Furthermore, all available raters (6 of 7)
were asked to guess the patient condition for each of their follow-up assessments (n=103); assessors made 50 correct guesses
and 53 incorrect guesses, a chance level of accuracy. Treatment assignment was known to therapists, patients, and, forlegal reasons, the treating psychiatrist. Other members of eachpatient’s nonstudy treatment teams (eg, group therapists, casemanagers) were not informed of treatment assignment.

Cognitive Therapy
Participants in the CT intervention were scheduled to receive
up to 18 months of outpatient CT sessions. The sessions typically lasted 50 minutes and were scheduled on a weekly basis;
however, based on the participant’s needs and progress, the duration and frequency of sessions as well as duration of treatment were flexible. The central features of this psychotherapy
were its goal-directed framework and personalized treatment
planning. Early sessions focused on engaging the patient andstrengthening the therapeutic relationship. Therapy aimed tostimulate patients’ interest and motivation to focus respec-

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tively on achievable long-term goals (eg, independent housing, employment, relationships), intermediate goals, and shortterm goals. Key impediments to reaching these goals are
dysfunctional beliefs (eg, “taking even a small risk is foolishbecause the loss is likely to be a disaster” and “making new
friends isn’t worth the energy it takes”). The therapists helped
patients to undercut their nihilistic beliefs and concomitantly
increase their motivation for constructive activity by using avariety of cognitive and behavioral techniques, including activities during the session (eg, exercises, games, role-playing,community outings) and collaboratively devised action plansfor practice outside the session. Other impediments to reaching the goals such as the presence of delusions, hallucinations, and disorganized thinking were also addressed by strategies outlined by Beck et al.33 Further, specific deficiencies suchas deficits in attention, executive function, and social skills weretargets for the therapy. Later sessions were devoted to consolidation of functional gains and relapse prevention. The treatment was tailored to the participant’s level of functioning, suchthat special adaptations were made for problems due to poor
engagement, neurocognitive impairment, thought disorder, andlack of insight. To accommodate neurocognitive impairments, for example, therapists made extensive use of visual aids,
including whiteboards for reinforcing session material, laminated cards to help patients remember key take-home points,
and colorful signs that patients posted at home to remind themof daily activities and other therapy assignments. The CT sessions followed a treatment manual and were administered bytherapists at the doctoral level (PhD and MD). Sessions werevideorecorded, and weekly supervision was provided by oneof us (A.T.B.).

177 Contacted forparticipation

52 Excluded prior tobaseline
48 Refused toparticipate
4 Not able toconsent forbaseline

125 Baseline completed
65 Excluded prior to randomization
44 Did not meet inclusion criteria
21 Not able to randomize
2 Died
7 Lost before randomization
5 Study filled before complete
7 Refused randomization
60 Randomized

Standard Treatment
Participants in both study conditions received ST from clinicians in the community. At minimum, this consisted of antipsychotic pharmacotherapy. However, most participants werealso actively engaged in services provided by local community
mental health centers, including case management, supportive counseling, day treatment services, housing services, peer
support, and vocational rehabilitation.

OUTCOMES
The primary objective of adding CT to ST was to aid the progress of patients with schizophrenia toward recovery by producing a clinically significant change in their functional outcome. The Global Assessment Scale (GAS)34 score was theprimary outcome measure. The GAS is a single-item interviewerscored instrument that assesses functioning level and symptoms during the previous month. The rating is made on a 100point scale, with lower scores indicating poorer functioning.
Endicott et al34 demonstrated test-retest reliability and predictive validity (rehospitalization rates) for the GAS in patientswith schizophrenia. Secondary measures were the 4 global subscale scores of the Scale for the Assessment of Negative Symptoms (SANS)29 and the total score of the Scale for the Assessment of Positive Symptoms (SAPS).35 The reliability and validityof the SANS and SAPS have been demonstrated.36 A recent consensus statement has proposed the SANS and SAPS as standard measures of negative and positive symptoms.37

SAMPLE SIZE
On the basis of a meta-analysis of medical and behavioral outcomes showing that an effect size of d = 0.5 between conditions has an effect on quality of life,38 we designated d=0.5 as

31 Allocated to CT with ST
28 Received CT
3 Refused CT

29 Allocated to ST alone
26 Received ST
3 Refused to participate

31 at 6-mo follow-up
30 Assessed
1 Died29 at 6-mo follow-up
24 Assessed
5 Withdrew or missed

31 at 12-mo follow-up
22 Assessed
1 Died
8 Withdrew or missed

29 at 12-mo follow-up
20 Assessed
9 Withdrew or missed

31 at 18-mo follow-up
21 Assessed
1 Died
9 Withdrew or missed

29 at 18-mo follow-up
18 Assessed
11 Withdrew or missed

31 Analyzed
0 Excluded

29 Analyzed
0 Excluded

Figure 1. Flowchart of the progress through the phases of the randomized
trial for the 2 groups. CT indicates cognitive therapy; ST, standard treatment.

the minimal clinically significant change that the trial would
be powered to detect. With a sample size of 60, expected dropout rate of 20%, 2-sided ␣ = .05, and within-subject correlation of 0.5, we determined that the study would have 80% power
to detect a true treatment difference in the rate of change offunctioning of 0.5 SD.

PLANNED ANALYSES
Linear random-effects models (hierarchical regression models) were implemented with random intercepts and slopes. Thesemodels estimate main effects for change from baseline to each
assessment at 6, 12, and 18 months, main effect for the treatment, and interactions between the visit and treatment indicator variables. For each of the primary (GAS) and secondary(SANS and SAPS) outcomes, separate intent-to-treat tests andestimates (with 95% CIs) of randomized group contrasts at
6, 12, and 18 months were obtained from the estimates of
the respective time⫻treatment interactions.39 Potential con-

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Table 1. Baseline Demographic and Clinical Characteristics

Characteristic
Age, mean (SD), y aMale, No. (%)
Race/ethnicity, No. (%)
African American
White
Asian American
Biracial
Schizophrenia diagnosis, No. (%)
Duration of illness, mean (SD), y
Age at onset, mean (SD), yAtypical antipsychotic
medication, No. (%) b
Chlorpromazine equivalents,
mean (SD), mg bCT(n = 31)ST(n = 29)34.3 (10.9)
21 (67.8)

42.9 (10.8)
19 (65.5)

20 (64.5)
10 (32.3)
1 (3.2)0
23 (74.2)
13.2 (11.0)
21.3 (7.2)
29 (93.5)

19 (65.5)
9 (31.0)0
1 (3.4)25 (86.2)
18.0 (12.8)
24.9 (9.4)
26 (89.7)

415.6 (168.4)

521.1 (271.1)

Abbreviations: CT, cognitive therapy; ST, standard treatment.
a P ⬍ .01.
b One person receiving CT was missing data.

60

Mean GAS Score

50
40
30
20
10
ST alone (n = 29)
CT with ST (n = 31)
0Baseline

6 mo

12 mo

18 mo∗

Assessment

Figure 2. Global functioning. The values at baseline are raw means; thevalues at 6, 12, and 18 months are adjusted means (SEs) from theintent-to-treat hierarchical linear models. CT indicates cognitive therapy;
GAS, Global Assessment Scale; and ST, standard treatment. *P= .03 for themean difference based on the hierarchical linear modeling interaction oftreatment condition ⫻assessment time.

Table 2. Intent-to-Treat Hierarchical Linear ModelingInteraction Effects of Condition ⴛ 18 Months
for Study Measures

MeasureNonstandardized
␤

95% CIt Value

9.0
−0.9
−7.7

0.98 to 17.11−1.64 to −0.18−14.97 to −0.50

t145 = 2.20
t145 = 2.20
t129 = −2.11

Global functioning a
Avolition-apathy b
Positive symptoms ca Global Assessment Scale score.
b Global subscale score on the Scale for the Assessment of Negative

Symptoms.
c Total score on the Scale for the Assessment of Positive Symptoms.

RESULTS

Between January 2007 and August 2009, 60 individuals wereentered into the study, with 31 randomly assigned to CT
with ST and 29 to ST alone. The mean (SD) age was 38.4
(11.6) years; 20 (33.3%) were female; and 39 (65.0%) were
African American. The mean (SD) age at illness onset was
23.1 (8.5) years, and the mean (SD) duration of illness was
15.5 (12.18) years. The mean (SD) neurocognitive impairment in tasks of memory, attention, and executive functioning as measured by a validated computerized battery41
was a z score of −1.0 (1.2) relative to a healthy referencegroup, indicating considerable impairment in the sample.
In terms of antipsychotic medication, 55 (91.7%) of the cohort was taking at least 1 atypical (second-generation) agent
and 39 (65.0%) of the sample had a chlorpromazine equivalent dosage of 400 mg or greater, indicating a high dosage.
There were no meaningful group differences in antipsychotic medications at baseline (Table 1 shows baseline
sample characteristics).
As displayed in Figure 1, the 18-month trial was completed by 27 of the 31 participants (87.1%) in the CT
group (1 died [hypertension] and 3 withdrew [refused
treatment]) and by 24 of the 29 participants (82.8%) in
the ST group (5 withdrew [2 moved away, 3 refused tocontinue participation]).
IMPLEMENTATION OF CT

founding variables were evaluated by assessing whether
baseline factors imbalanced between the treatment groups
were related to outcome. Age was found to be a confounding
variable ( Table 1 ) and was controlled in all analyses.
Although the study was designed to minimize lost observations, the random-effects or hierarchical regression approachis superior to last observation carried forward in minimizing
bias and type I error and is inferentially equivalent to multiple imputation.40
Intent-to-treat analyses using hierarchical linear modelingwere conducted on all outcome measures. The hierarchical linear modeling analysis is able to identify differences between conditions by the presence of a significant month⫻treatment interaction term. For example, a significant month⫻treatment
interaction in favor of CT on the GAS score at 18 months would
support the hypothesis that CT with ST is more efficacious thanST alone at improving functioning. Similar intent-to-treat analyses were run for negative and positive symptoms. Reported variances are standard deviations unless otherwise specified. Analyses were conducted using IBM SPSS version 19.0 statisticalsoftware (IBM Corp, Armonk, New York).

The mean (SD) number of CT sessions for the 28 patients who engaged in treatment was 50.5 (18.9) (range,
16-81). The 8 therapists (with PhD and MD degrees), eachhaving at least 2 years of experience with CT, treated anaverage of 3.5 patients (range, 1-7 patients).
TREATMENT WITH MEDICATIONSThere was no difference across the 2 conditions in
the number of patients who changed medications or
dosages.
OUTCOMESThe CT group improved on global functioning (GAS
score) during the course of the trial (within-group Cohen d =1.36), whereas the ST group improved very little(within-group d = 0.06) (Figure 2). In the intent-to-

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B
4.0

4.0

3.5

3.5

Mean SANS Global Score

Mean SANS Global Score

A

3.0
2.5
2.0
1.5
1.0
0.5

ST alone (n = 29)
CT with ST (n = 31)

2.5
2.0
1.5
1.0
0.5

0.0
Baseline

3.0

0.0
6 mo

12 mo

18 mo∗

Baseline

6 moAssessment
C

18 mo

12 mo

18 mo

D
4.0

4.0

3.5

3.5

Mean SANS Global Score

Mean SANS Global Score

12 moAssessment

3.0
2.5
2.0
1.5
1.0
0.5

2.5
2.0
1.5
1.0
0.5

0.0
Baseline

3.0

0.0
6 mo

12 mo

18 mo

Baseline

6 moAssessment

Assessment

Figure 3. Negative symptoms. The mean global scores for the avolition-apathy (A), anhedonia-asociality (B), affective flattening (C), and alogia (D) subscales of
the Scale for the Assessment of Negative Symptoms (SANS) are shown. The values at baseline are raw means; the values at 6, 12, and 18 months are adjusted
means (SEs) from the intent-to-treat hierarchical linear models. CT indicates cognitive therapy; ST, standard treatment. *P = .01 for the mean difference based on
the hierarchical linear modeling interaction of treatment condition ⫻ assessment time.

COMMENT

We found that patients assigned to CT had better functioning, reduced avolition-apathy, and improved positive symptoms relative to patients who received ST only.

25

20

Mean SAPS Total Score

treat hierarchical linear model (Table 2), the interaction term for the condition⫻GAS score at 18 months was
statistically significant (P = .03), indicating that the CT
group had functioning superior to that of the ST groupat 18 months (adjusted mean [SE], 58.3 [3.30] vs 47.9
[3.60], respectively; between-group d = 0.56).
On the 4 SANS negative symptom subscales (Figure 3),
the CT group showed greater improvement than the ST
group across the trial for avolition-apathy (at 18 months:
within-group d, −2.16 vs −0.45, respectively; for interaction term of condition⫻18 months, P=.01; adjusted mean[SE], 1.66 [0.31] vs 2.81 [0.34], respectively; betweengroup d=−0.66). There were no significant group differences for the other negative symptoms (affective flattening, alogia, anhedonia-asociality).
In terms of positive symptoms (Figure 4), the CT
group showed greater improvement than the ST groupacross the trial (at 18 months: within-group d, −0.90 vs0.37, respectively; for interaction term of condition⫻18 months, P = .04; adjusted mean [SE], 9.4 [3.3]vs 18.2 [3.8], respectively; between-group d= −0.46).

15

10

5
ST alone (n = 29)
CT with ST (n = 31)
0Baseline

6 mo

12 mo

18 mo∗

Assessment

Figure 4. Positive symptoms. The values at baseline are raw means; thevalues at 6, 12, and 18 months are adjusted means (SEs) from theintent-to-treat hierarchical linear models. CT indicates cognitive therapy;
SAPS, Scale for the Assessment of Positive Symptoms; and ST, standard
treatment. *P = .04 for the mean difference based on the hierarchical linear
modeling interaction of treatment condition ⫻ assessment time.

Group differences were statistically significant and clinically meaningful. This is the first time, to our knowledge, that patients with chronic schizophrenia selectedfrom the extreme end of the low-functioning continuum have shown statistically significant and clini-

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cally meaningful improvement in psychosocial functioning in response to a psychosocial intervention.
Taking the results of functional outcome, motivation, and positive symptoms together, we propose thatthe patients who received CT entered into a dynamic cycleof recovery. The treatment encourages the patients to set
goals related to their everyday functioning, and they become motivated to engage in tasks (initially simple pleasurable, social, and constructive activities) that move themout of their withdrawn state. This increase in activity andmotivation puts the patients more in touch with reality
and reduces hallucinations, delusions, and disorganization. Reduced positive symptoms allow for further engagement in activity, leading to better functional outcomes and enhancement of motivation, which in turnfacilitate a further amelioration of positive symptoms.
Thus, we hypothesize that CT triggers the cycle of recovery by targeting self-defeating and dysfunctional beliefs that inhibit the patients’ active engagement in constructive activity. Alternatively, it is possible that
improvement in avolition-apathy was largely secondary
to improvement in positive symptoms. These are questions that can be addressed by future research.
There are several limitations of this study. First, the measures of functioning and symptoms have been criticized.8,42 For instance, the GAS includes symptoms in theratings and, as such, is not a pure measure of functional
outcome. Use of the newly developed Schizophrenia Outcomes Functioning Interview43 and Clinical Assessment
Interview for Negative Symptoms44 is warranted in future clinical trials of CT. More frequent assessment of symptoms and functioning would allow for better tracking ofchanges over time. Also, the therapy was delivered by doctoral-level therapists; generalization to masters-level community therapists who treat low-functioning patients remains to be demonstrated in future research. The CT
condition involved more patient contact than the ST condition, raising the possibility that nonspecific patient contact factors are contributing to the observed group differences. Additionally, both therapists and patients were awareof the condition and participation in an experiment, introducing possible bias in the reported outcomes. Futurestudies can address nonspecific factors and bias due tosingle-blind design, as well as other factors, by comparing the CT protocol with active psychotherapy comparison conditions that feature treatments (eg, social skills)
that have received empirical support for patients withschizophrenia. Finally, it remains for future studies withrevised CT protocols to demonstrate efficacy relative toanhedonia, affective flattening, and alogia.
The major findings of this study—that CT improved
functioning and motivation and reduced positive symptoms in low-functioning patients with schizophrenia—
suggest that this treatment might have utility to help reduce public health costs for the most expensive
per-patient psychiatric population while simultaneously improving patients’ quality of life.
Submitted for Publication: May 17, 2011; final revision
received July 13, 2011; accepted July 16, 2011.
Published Online: October 3, 2011. doi:10.1001/archgenpsychiatry.2011.129

Correspondence: Paul M. Grant, PhD, Perelman Schoolof Medicine, University of Pennsylvania, Room 2032, 3535
Market St, Philadelphia, PA 19104 (pgrant@mail.med.upenn.edu).
Author Contributions: Dr Grant had full access to all of
the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: Drs Grant, Stolar, and Beck havereceived royalties from Guilford Press.
Funding/Support: This work was supported by a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression (DrBeck) and by grants from the Heinz Foundation and the
Barbara and Henry Jordan Foundation.
Role of the Sponsors: The sponsors had no role in design and conduct of the study; collection, management,
analysis, and interpretation of the data; or preparation,
review, or approval of the manuscript.
Additional Contributions: We express our gratitude to
the patients who participated in this research and thereby
made it possible. We also thank Arthur Evans Jr, PhD,
and the City of Philadelphia Department of Behavioral
Health; Roy Beck, MD, PhD; Thomas R. Ten Have, PhD,
MPH; Robert A. Steer, EdD; Robert DeRubeis, PhD;
LaRiena Ralph, BS, and Jan A. Richard, MS, Hospital of
the University of Pennsylvania; and Gail Serruya, MD,
Sunil Bhar, PhD, Sally Riggs, ClinPsyD, Luke Schultz, PhD,
Jarrod Reisweber, PsyD, Nadine Chang, PhD, Amy
Wenzel, PhD, Maureen Endres, MS, Mary Tabit, MS,
Heath Hodges, MS, Kara Devers, MSEd, Sean Gallagher,
MS, Jason Cha, MSEd, Ashley Chambers, MS, Michael
Ovalle, MEd, and Letitia Travaglini, BS, University ofPennsylvania, for their assistance with this project.
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